Predictors of emotional exhaustion among physicians from Iraq-a descriptive cross-sectional multicentre study

Background: Doctors and paramedics in countries suffering from long acting conflicts including Iraq are working in serious and exceptional conditions, putting them under severe physical and psychological pressure, therefore examining burnout is important when dealing with quality of care and working conditions. The aim of this study was to assess the point prevalence and to explore factors associated with emotional exhaustion (EE) among medical doctors in Iraq. Methods: Descriptive and cross sectional study was conducted (January to June 2014) among a randomly selected sample of medical doctors (n=576, 87.3% response rate) working in twenty large general hospitals and medical centers. In additions to EE, the self-administered questionnaire used consisting of questions on sociodemographic, work-related characteristics, conflict-related variables and job satisfaction. EE was measured using the emotional exhaustion subscale of the Maslach Burnout Inventory (MBI). Results: The prevalence of EE was reported by 60.0% of the respondents. In multiple linear regression analysis the emotional burnout was higher among doctors who were married, female, bearing children, being threatened, displaced internally, non-specialist doctors, working more than 40 hours per week, experienced unsafe medical practice, disagreed with the way manger handle the staff and those who reported that the doctor-patient relationship as not excellent. Conclusion: Our findings suggest that job dissatisfaction, conflict and violence related factors were significantly associated with high level of emotional exhaustion among Iraqi physician.


Background
The burnout syndrome has been widely discussed since its first time emerged in its three dimensions; emotional exhaustion, depersonalization, and low personal accomplishment [1].Workrelated burnout is becoming increasingly recognized as a serious problem affecting many people working in human services, especially healthcare workers [2].It has been shown to be directly related to a considerable list of adverse outcomes, including absenteeism from work, increased turnover and poor job performance [3].Burnout has also been shown to have effects on physicians and their mental and physical health [4,5], in addition to the clinical performance and the quality of care [6,7].These features have been regularly reviewed and recognized over the past fifty years [8].Literature suggest that burnout is a common health problem among doctors in different countries globally [9][10][11][12].However, despite such wide recognition in Western societies, the subject of burnout has not received the required attention from the Middle East researchers until the beginning of 21st century, and to our knowledge, there is a lack of national studies on burnout among Iraqi health workers.This is a particular problem in Iraq where the health care system has suffered a long standing catastrophic collapse since 1991 and has been overloaded since that time [13].Furthermore, after the US-led invasion of Iraq in 2003, health system exposed to deliberated destruction of its infrastructure accompanied with new exodus of brain drain including the medical doctors [14].In fact, the high level of violence in ___________________________________________________ drsaadalezzi@gmail.com 1 Department of Public Health, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey Full list of author information is available at the end of the article conflict zones such as Iraq produced chronic stress among health personnel, so that continuity in work became almost impossible [15].Moreover, lack of services and the attempt of government to spoil the doctor-patient relationship by directing the media to focus mainly on the performance of health care providers made them victims of unfortunate and unjustified incidents of different type of abuse [15,16].Thus, the combination of lack of security, work and violence related and political factors has significantly contributed to raise the level of turnover intention and migration among Iraqi doctors.Consequently, the staying doctors, who are still working in Iraq, were not able to cope with the resultant weakness in the level of health service presented to the patients who already feel dissatisfied and carry negative impression against this service [17][18][19].As a results, the doctors are more likely to pass into a state of an inevitable physical and emotional exhaustion (EE) ending to an exaggerated motivation to leave job and looking for a better opportunity outside their country [14][15][16][17][18][19].
This study aimed to predict the main factors related to emotional burnout among Iraqi doctors working in different health care centers during the eruption of armed conflict in 2014.The study focused on Job satisfaction, violence-related variables, work-related variables, and socio-demographic factors to investigate their interrelationships with EE.

Study design and subjects
This cross-sectional study was conducted among Iraqi medical doctors to test the impact of violence-related and workplacerelated variables on the Overall EE.The present study is part of a larger research initiative [14,15], in which we recruited a multistage sampling technique to drew a random sample of 660 physicians from twenty large general hospitals and medical centers covering the main five geographically regions in Iraq (north, west, south, central, and the capital city).Design, sampling, and data collection have been reported in detail previously [14,15].In current analysis, responses were received from 576 physicians (response rate 87.3%).At the time of survey, all Iraqi physicians working at the selected hospitals were included and received a copy of the self-administered questionnaire manually with contact number and email of the data collector.The exclusion criteria included the chief medical officers (CMO), hospital managers and their deputies.

Outcome variable
Emotional burnout was assessed by nine items of EE subscale of the validated Maslach Burnout Inventory (MBI) [20][21][22].EE were answered in terms of frequency on a 7-point Likert scale ranging from 0 (never) to 6 (every day).The overall EE was measured by summing the scores of the 9 items (in range of 0 to 54).A higher score indicated greater emotional exhaustion [3] and, accordingly, a higher emotional burnout.The Cronbach's alpha coefficient of the EE subscale reported in this study was 0.89.

Independent variables
Job satisfaction was measured with the 10-item Warr-Cook-Wall (WCW) job satisfaction (seven-point Likert-type) scale ranging from 1 = "very dissatisfied" to 7 = "very satisfied".The overall job satisfaction was measured by summing the scores of the 10 items (in range of 10 to 70).
The socio-demographic variables were collapsed and coded as follows: age (more or less than 40 years old); gender (male or female), marital status (married or single), presence of children (yes or no), residency (Urban or rural).Variables of conflicts or war-related violence were collapsed and coded as either (1) "Yes" or (0) "No" in response to the following questions: "Because of war violence in Iraq, have you been lost a family member?";"Have you been threatened?";"Have you been displaced internally?"; "Do you think that medical practice is safe?" and "The doctor-patient-relationship is excellent?".
Individual work-related variables were categorized as follows: the current professional level (specialist or not); the working hours per week (more or less than 40 hours / week); the number of years spent at their work or the same facility (more or less than 10 years); the type of employment (government only or dual in government and private); the training and educational opportunities (yes or no); The way the senior manager handles the staff is effective (agreed or disagreed).

Statistical analysis
The Statistical Package for Social Sciences (SPSS) version 16.0 was used to analyze data in this study.Descriptive analysis on sociodemographic, conflict-related variables, work-related characteristics and job satisfaction was performed.The 9 items of emotional exhaustion subscale were summed to obtain the total score (0 to 54).A high degree emotional burnout was based on the cut-off point of the emotional exhaustion subscale in the MBI (≥27) [3].Data were presented as mean and standard deviation (SD).Test of normality of the total score of emotional exhaustion was conducted.
Student's -test was used to compare the mean of emotional burnout score across demographic variables, work-related characteristics, conflict-related variables and job satisfaction.Categorical data were presented as numbers and percentages and the chi-squared test was used for statistical analysis.Multivariate linear regression using "Backward" technique was employed to obtain factors associated significantly with emotional burnout score.Variables that were significantly associated with burnout in the bivariate analysis were included in the multivariate analysis.The accepted level of significance was set below 0.05 ( < 0.05).

Emotional exhaustion (Burnout)
The mean (±SD) value on the total emotional exhaustion score was 28.72 (SD = 7.30).Three hundred and forty five respondents (60.0%) experienced high level of emotional burnout (Table 2).

Work -related variables on overall emotional exhaustion
In table 4, the vast majority (73.3%) of respondents spent more than 10 years in the same health facility, and were not being specialist yet (60.2%), however more than half of them (55.7%) have dual job (government and private) and were satisfied with the available training and educational opportunities.Overall emotional exhaustion was higher among doctors who were not specialist (95% CI = 0.72-3.14,p=0.002), disagreed with the way manger handles the staff (95% CI = 0.72-3.14,p=0.003) and those who are working more than 40 hours per week (95% CI = 0.59-2.97,p=0.003).

Predictors of burnout
Table 5 shows the results of multiple linear regression analysis to identify the associated variables with emotional burnout.In backward elimination (or backward deletion) the multivariate linear regression analysis (after excluding of non-contributing variables ) was statistically significant, and overall, explained 24.8% of the variance in the overall emotional exhaustion, F (11, 16.845) = 680.670,P < .0005.The "Internally displaced" and the "doctors-patient relationship" appeared to be the strongest factors predicting the EE (Table 5).Doctors who were internally displaced were more likely to have high EE (B = 0.269, P < .0005).Doctors who considered the doctor-Patient relationship is not excellent were more likely to have high EE (B = 0.267, P < .0005).In general, the emotional burnout was higher among doctors who were married, female, bearing children, being threatened, displaced internally, non-specialist doctors, working more than 40 hours per week, experienced unsafe medical practice, disagreed with the way manger handle the staff and considered the doctor-patient relationship as not excellent.

Discussion
It was an interesting exercise to test several factors that may predict the EE among Iraqi doctors.However, it was not possible to capture all possible factors.Only 24.8% of the variation was explained; 75.2% of the variation remained unexplained.Clearly, other factors may affect the EE.In this study, the mean value of the total burnout score among Iraqi physicians was found to be 28.72 (SD=7.3,range 0-54).Around 60% of the study participants revealed experiencing high level of emotional burnout.This finding is consistent with other international studies.Elsewhere in the Middle East, burnout has been found to be quite common among health professionals in Tunisia [23].In Saudi Arabia, a high prevalence of burnout among multinational health professionals has been reported [24].A quarter of the health professionals had suffered from high levels of burnout in Egypt [25].In contrast, a study conducted in Qatar found that only 12.6% of responding primary care physicians experienced burnout [26].The first step in coping with burnout threats is to identify the most common causes.The results from previous studies show that among the doctors, burnout is the result of exposure to factors associated with both personal and work environments.Taking into consideration the conclusions from previous studies and the different health system and culture in Iraq, in the current study, the following factors were investigated for their association with burnout, with the aim of reducing burnout among Iraqi doctors: socio-demographic variables (age, gender, marital status, presence of children, residency), work-related variables (job satisfaction, being specialist, years of service, less than 40 hours of work per week, working in both government and private sector, managers handle staff well, poor doctorpatient relationship), and workplace violence variables (loss of family member, exposure to threat or kidnapping, internally displaced, unsafe medical practice).Eleven of these factors maintained in the backward regression analysis.Thus, burnout is potentially multi-determined, therefore, any type of prevention or intervention will require multi-faceted approaches.
In our study, multivariate regression analysis of variables affecting burnout revealed that among the demographic factors, being female, having children or being married are significant predictors of burnout among the study population in Iraq.Regarding to the role of gender in burnout, some papers found female doctors to be at a higher risk of burnout [27,28].This is in agreement with the findings of the present study.However, only few studies reported burnout by sex, and a study conducted across Europe found burnout to be more prevalent amongst males [29].In our study, married physicians and physicians having children are expected to have higher level of burnout than their counterparts.In a study in Turkey, it was reported that problems with childcare were significantly associated with burnout [30].Disequilibrium between family and work demands was found to be one of the most important factors contributing to burnout among Iraqi physicians [31].In contrast, unmarried physicians were found to have a higher level of burnout and more desensitization in a few other studies [32,33].Physicians are exposed to a variety of work-related factors that are important in creating burnout.
This study showed that the prevalence of burnout is higher in physicians reporting lower job satisfaction.The entire literature evaluating the correlation between job satisfaction and burnout has yielded the same result [34][35][36][37][38].However, the majority of the literature is based on cross-sectional surveys as it does in this study, which makes it difficult to verify a causality.While the researchers suggest that low job satisfaction was a risk factor for burnout, it can be asserted that burnout is a risk factor for low job satisfaction, or poor job satisfaction may itself be a symptom of burnout.Further research is needed to clarify the negative relationship.
Among the work-related factors, work time and the doctorpatient relationship are two other factors that have been shown to be related to burnout, in both this and previous studies [39][40][41][42].Physicians in the current study who worked more than 40 hours per week or reported dissatisfaction with doctor-patient relationship had significantly higher burnout rates.Iraqi healthcare system has faced a catastrophic collapse since 1991.Iraqi doctors have left the country due to falling wages and worsening security conditions during the sanction years and after the 2003 invasion [43].Even though the migration rates have slowed more recently, it was estimated that about half of the doctors have already left Iraq after the 2003 invasion, and most healthcare providers have significant turnover intentions or to leave the country [44].In addition, health care system has been rapidly changing in recent years, which have increased many doctors' responsibilities, as well as demands of their patients.As a result, doctors are working longer hours and taking less time to communicate with patients, and medical disputes often occur caused by patient dissatisfaction.These combined effects have created an increasing conflict between patients and doctors and damaged the doctor-patient relationship [14].Consequently, organizational interventions such as reducing long working hours and developing doctorpatient relationships should be considered in new health care reforms.The doctor-patient relationship needs be improved through the implementation of various measures, including malpractice insurance for physicians and improving doctorpatient communication [45].
There is broad acceptance that work satisfaction and burnout levels are strongly affected by the leadership skills of senior managers.Previous studies have shown that relationship with managers is an important factor that affect burnout [46,47].Poor relationships with managers can lead to feelings of exclusion and loneliness among physicians that can easily turn into burnout [20].Our study reported similar results; physicians who reported low managerial skills of their immediate supervisors have higher rates of burnout.The findings in this study contribute to the understanding that high levels of managerial support and skills have positive effects on fighting with burnout.The reduction of occupational stress, development of managerial skills of supervisors and strengthening relationship with managers can decrease burnout and improve quality of life of physicians, as seen in other studies [48] [50].
Further, non-specialist physicians are found to be at high risk of burnout in our study group.This finding is similar to the results of other studies.For example, in a Finnish study, the highest burnout scores were noted in general practitioners and non-specialists working in health centers.This was due to heavy patient loads, long hours of work, low salaries, and professional identity issues [49].Conflict-related factors and workplace violence have not been systematically examined as a predictor of physician's burnout except a few studies.The present study results demonstrated that physicians who were threatened, who were displaced internally, or who believed medical practice was not safe were more likely to have higher burnout rates in our studied sample.Previous studies in Egypt, Poland, Turkey and a meta-sample of seven studies from different regions also demonstrated that workplace violence, conflicts, personal threats, or incivility were positively associated with the psychological conditions of physicians, including burnout [25,50,51].
There are some limitations to this study.First of all, because the study design was cross-sectional, a causal relationship could not be established.Second, because we had no information about the non-respondents , response bias is a possible bias.Third, this study was conducted during a peak crises of conflict in 2014 which affected the accessibility to the hospitals and districts and consequently a selection bias is another possible bias.Fourth, "Although we have test piloted the English version of the questionnaire, the language barrier could be a limitation because the native language of the respondent is Arabic".

Policy implication
The above findings may can be applied to the design and implementation of burnout reduction programs in Iraq and facilitate the development of rational strategies.For example, the results showed burnout in physicians to be higher in females, married, or individuals with children.Therefore, we suggest that the target group of burnout reduction programs should primarily focus on these physicians.Intervention strategies may cover communication skill training, stress and time management.Further, burnout was found to be associated with work-related factors: job satisfaction, working hours, being non-specialist, poor relation with managers and patients.Improving working conditions of Iraqi doctors should be an important goal for their job satisfaction and low burnout levels.Policy reforms can address these factors contributing to burnout by reducing workload, reasonable welfare, a healthier working environment and senior-junior support groups.Increasing compensation can be an effective method to help attracting and retaining good doctors.A large proportion of patients in hospitals are affecting the quality of care and the doctor-patient relationship and therefore the burnout of doctors.A comprehensive health care reform is needed to strengthen primary health care intended to address the overutilization of hospitals.This may involve the government hiring and training more staff.Conflict and violence related factors were found to be significantly associated with burnout of Iraqi physicians in current study.Measures to prevent violence in workplace against doctors are needed to reduce risk and negative consequences.Although health institutions in general have made considerable progress in the development of programs to prevent violence in Iraq, there are still shortcomings in the legislation prohibiting violence at work, and it is essential that laws are enacted to improve the medical environment and prevent violence at work.In order to effectively carry out these policies, government and health care organizations must develop, implement, and encourage a strong safety and security environment.[51].

Conclusion
High level of emotional exhaustion has been detected in about two third (60.0%) of participants.Findings of this study show that various socio-demographic, occupational and conflictrelated factors are important determinants of the burnout of Iraqi doctors.The results of this study would therefore be of great interest to Iraqi policy makers and health care managers seeking to reduce physician burnout levels.The importance of burnout in physicians should not be underestimated and many of the associated factors identified may potentially be reversed.This study may serve as a guide for setting effective interventions and treatment.According to the results, the focus should not only be on providing financial incentives but also on special efforts to create a safe and acceptable work environment.
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Table 2
Descriptive statistics of the 9 items and overall emotional exhaustion scale

Table 3
Conflict and war-related variables on overall emotional exhaustion (n=576)

Table 4
Work -related variables on overall emotional exhaustion (n=576)

Table 5
Factors associated with emotional exhaustion in multiple linear regressions (n=576)